ResultsResults of ACL reconstruction for of ACL reconstruction for chronicchronic kneeknee instabilityinstability, , usingusing one one thirdthird of the of the patellarpatellar tendon tendon augmentedaugmented by by extraextra--

articulararticular plastyplasty" Mac " Mac InJonesInJones" " operationoperation

100 cases 100 cases -- followfollow--upup > 10 > 10 yearsyears

Materiel and methodsMaterielMateriel andand methodsmethods

Prospective study1OO knees from 134 consecutive operations

(1 surgeon, 1 technique)

• Chronic cases• Accident to surgery interval : 4 ± 4.8 ys• Mean age : 27.8 ± 9 years• Males : 58 %• Sport’s trauma : 83 %• Previous surgery in 32 cases :

15 ACL reconstructions,Meniscal resections : 18 med, 5 lat

• Follow-up : 11.7 ± 2 ys (10 to 16)

"Mac InJones » procedure

• Patellar tendon (10 mm)• Quadricipital tendon : 12 cm• Trapezoïdal shaped patellar bone

• Special femoral visor• Diameter : 9 mm • bone is recuperated

((Derived from bothDerived from both MacIntosh MacIntosh and and Jones Jones proceduresprocedures))

Free Free graftgraft

Introduction from outside to inside through the condyle

Stability of the trapezoïdal patellar block into the tunnel by pushing with a hammer

Fixation in the tibia with ametallic wire and a screw

Progressive tension untilsuppression of the drawer

Bony fragments into the tibial tunnel

Sometimes 1 additional interference screw

"Mac InJones » procedure

1rst step : ACL reconstruction

2d 2d stepstep : : LateralLateral extraextra--articulararticular plastyplasty

QuadricipitalQuadricipital tendon tendon isis stretchedstretched fromfrom the condyle the condyle to the Gerdyto the Gerdy’’s tubercule s tubercule withwith solidsolid suturessutures

"Mac InJones » procedure

"Mac InJones » procedure

With this procedure and the tension adjusted by torsion of

a metallic wire on a screwJL Lerat (1979)

It had become clear than thegraft was sufficiently solidly

fixed at both its ends to authorize

immediate mobilisationin full flexion and extensionand agressive rehabilitation

program JL Lerat (1979)

1rst case 19791rst case 1979

QuadricipitalQuadricipital tendon tendon isis stretchedstretched fromfrom the condyle the condyle to the Gerdyto the Gerdy’’s tubercule s tubercule withwith solidsolid sutures sutures

Fragments of Fragments of bone fillbone fillthe the patellar patellar trenchtrench

Mean Mean skin incision : 13 cm skin incision : 13 cm ±± 33

MaterielMaterielMateriel

100 knees evaluated

• 88 examinated and radiographied• + 12 questionnaires

17 patients lost for follow-up

+ 3 patients died

AnatomicalAnatomical valuevalue

-- KTKT--1000 1000 arthrometerarthrometer-- AnteriorAnterior radiologicalradiological

drawerdrawer

FunctionFunction

-- IKDCIKDC (International (International KneeKneeDocumentation Documentation CommiteeCommitee))

-- A.R.P.E.GE scoreA.R.P.E.GE score

MethodsMethodsMethods

MethodsMethods

KT-1000 Arthrometer(preop - post-op)

• KT 1 : 69 n• KT 2 : 89 n• KT 3 : maxi-manual

Stress radiography(preop - post-op)

• 20° of flexion• Load : 9 kg• Translation of medial and

lateral compartments

Per-operative findings

• Medial meniscus lesions : 30 %+ 25 previous meniscectomies = 55 %

• Lateral meniscus lesions : 19 %

• Cartilages lesions : 19 %– Medial : 12– Lateral : 4– Both : 3

Complications

• 7 ematomas• 2 DVT• 1 temporary peroneal nerve palsy• 2 SND• 3 skin infections • 1 infection

Results Results Results

• Flexion : 143° ± 11• Flexion contracture : 4.5° ± 7• Amyotrophy : 1 cm ± 0.8 (28 having none)

• Recurrence of laxity : 9 cases• Pivot-shift test

++ : 3 %+ : 22 %

0

10

20

30

40

50

60

Pain effusion apprehension

Activity +++activity ++activity +sedentary

SymptomsSymptoms according according toto activity level activity level

Functional resultsFunctional results

05

101520253035404550

Excellent- A

Good - B Poor - C Bad - D

ARPEGE scoreIKDC

A.R.P.E.GE : 60 % excellent + good

IKDC score : 61 % excellent + good

0 10 20 30 40 50

sports

No sportotherVolleyTennisSkirugbyfightMountainBasketFootballRunningBasket

CompetitionCompetition : 58: 58

Recreative Recreative : 35: 35

Sport Sport before before traumatrauma

0

10

20

30

40

50

60

pivot-contact

pivot Withoutpivot

Nosport

Before trauma

preop

follow-up

Sport Sport activityactivity• Satisfaction expressed by the patients : 88 %• 78 % of the patients return to sport activities• Sport with pivot : 30 % (competition : 17 %) • 14 patients stop sport for other reasons

0

10

20

30

40

50

60

70

competition recreative active sedentary

before traumapreopfollow-up

EvolutionEvolution of sport of sport activity levelactivity level

02468

10121416

preop G.A preop G.A post-op

6 m 10 years

KT 1KT 2KT3

ArthrometricArthrometric evolutionevolution

KT-1000 Arthrometer KT 1 : 69 nKT 2 : 89 nKT 3 : maxi-manual

« Knee instability after injury to the anterior cruciate ligament

Quantification of the Lachman test »

JL Lerat, B Moyen, F Cladière, JL Besse, H Abidi

J. Bone Joint Surgery VOL. 82-B, N°1, January 2000, 42-47.

Radiological anterior drawerRadiological anterior drawer

AnteriorAnterior radiologicalradiological drawerdrawer

ATMC: ATMC: Anterior Anterior Translation of Translation of Medial CompartmentMedial Compartment

ATLC : ATLC : Anterior Anterior Translation of Translation of Lateral CompartmentLateral Compartment

•• Flexion : 20Flexion : 20°°•• Load Load : 9 kg : 9 kg •• Free rotationFree rotation•• ComfortableComfortable for the for the

patientpatient•• Simple Simple apparatusapparatus

PathologicalPathological ATMCATMC andand ATLCATLC

AnteriorAnterior radiologicalradiological drawerdrawer

Differential laxity

PathologicalPathological ATMCATMC and and ATLC ATLC Normal Normal contralateral kneecontralateral knee

Precice and objective measurement of preop and post-op laxity

PathologicalPathological ATMCATMC and and ATLC ATLC Post Post op op 10 10 yearsyears

ACL ACL deficient kneesdeficient knees : : differential antdifferential ant. translation. translation

ATLC7.3 ± 4 mm

ATMC

7.8 ± 4.2 mm

0

10

20

30

40

50

60

70

80

-5 0 5 10 15 20 25

Differential ATLC

0

10

20

30

40

50

60

70

80

-5 0 5 10 15 20

Differential ATMC

Evolution of Evolution of radiologicalradiological laxitylaxity

0123456789

preop 6 m 1 year > 10 y

ATMCATLC

Gain for ATMC : 62 % Gain for ATMC : 62 % Gain for ATLC : 77 %Gain for ATLC : 77 %

Differential sideDifferential side to to side laxityside laxity

AB/AC x 100AB/AC x 100 AT/AC x 100AT/AC x 100 IT/IE x 100IT/IE x 100

68.6 % 68.6 % ±± 9.7 9.7 32.7 % 32.7 % ±± 88 44 % 44 % ±± 5.25.2

0

5

10

15

20

25

30

<50% 51-55 56-60 61-65 66-70 71-75 76-80 >80 21-25

26-30

31-35

36-40

41-45

46-48

0

5

10

15

20

25

30

35

21-25

26-30

31-35

36-40

41-45

46-48

iti d t l tibi l f

05

1015202530354045

28-40 41-45 46-50 51-57

FemoralFemoral tunnel : tunnel : AgliettiAglietti index index

0

5

10

15

20

25

30

<50% 51-55 56-60 61-65 66-70 71-75 76-80 >80

casescases

index in %index in %

AB / AC x 100 AB / AC x 100 68.6 %68.6 %±± 9.79.7

28-40 41-45 46-50 51-5705

1015202530354045

28-40 41-45 46-50 51-57

casescases

index in %index in %

Tibial tunnelTibial tunnel

21-25

26-30

31-35

36-40

41-45

46-48

0

5

10

15

20

25

30

35

21-25

26-30

31-35

36-40

41-45

46-48

iti d t l tibi l f

ProfileProfile AA--PP

3232 % % ±± 88 4444 % % ±± 5.25.2

CorrelationCorrelation position of the tunnels/position of the tunnels/goodgood resultresult

FemoralFemoral tunneltunnelAnteriorAnterior (< 52%) : IKDC : 0 A , 4 B, 9 C(< 52%) : IKDC : 0 A , 4 B, 9 CPosteriorPosterior (> 80%) : IKDC : 0 A, 6 B, 2 D(> 80%) : IKDC : 0 A, 6 B, 2 D

Tibial tunnel ATibial tunnel A--�P �P No No goodgood resultresult if < 30 ou > 50 % if < 30 ou > 50 %

Tibial tunnel (profile) Tibial tunnel (profile) AnteriorAnterior (< 25 %) : IKDC : 4 A, 8 B, 2 C(< 25 %) : IKDC : 4 A, 8 B, 2 CPosteriorPosterior (> 40 %) : IKDC : 8 C ou D(> 40 %) : IKDC : 8 C ou D

Difficulty Difficulty to to seesee the position of the the position of the ligament ligament into into the tunnels on the Xthe tunnels on the X--raysrays

Secondary operations

• Flexion under G.A (6 %)• 16 arthroscopies (8 meniscectomies : 5 med, 3 lat)• 3 arthrotomies (osteophytes)• Removal of 4 screws• 1 tibial osteotomy• 2 iterative ACL reconstructions

Degeneratives lesions

• 8 secondary meniscectomies during 10 years(10 times minor than during the 4 preop years)

• Correlation : Arthrosis / meniscal lesions

• Correlation : Arthrosis / Laxity(Differential laxity : 5.7 vs 8.3 mm)

Les séquelles survenant au niveau du système extenseur, après le prélèvement d'un transplant pour intervention de

type "Mac InJones "

« The sequelae resulting from extensor muscle graft for ACL reconstruction with "Mac InJones" procedure »

JL. Lerat, JL Besse, B. Moyen, E. Brunet-Guedj

Revue de Chirurgie Orthopédique, 1995, 81, 404-410

Patellar height modifications

Preop Post-op Difference

• Blackburne O.72 ± 0.17 0.69 ± 0.16 - O.028• Caton 0.87 ± 0.16 0.86 ± 0.15 - 0.01• Insall 1.11 ± 0.19 1.07 ± 0.20 - O.037

Comparison Comparison of 3 of 3 different different indexindex

No significative modifications for No significative modifications for patellapatella

• Patellar tendon• Anterior knee pain• Flexion• Flexion contracture• Calcifications (29 %)

– sup pole of the patella : 12– Patellar tendon : 4 – inf pole : 6– None of these calcifications requiered repeat surgery

• Quadriceps value

INFLUENCED BY

• Varus • Residual laxity• Pivot shift• Medial meniscus lesions

(57 %) • Long time before

operation (> 4 y)

ARTHROSISARTHROSISARTHROSIS

Evolution of Evolution of arthrosisarthrosis

JOINTSPACE

F-Tmedial

F-Tlateral

F-P F-Tmedial

F-Tlateral

F-P

Normal 76 97 93.5 30.5 78 66.3Remodeled 15.5 0.7 6.5 44.5 13.5 20.5

Stage I 7 1.5 0 11.5 5.3 9.6Stage II 1.5 0.7 0 13.5 3.1 3.6

prepre--opop postpost--opop

%%

StudyStudy of the of the failedfailed cases :cases :Ruptures or elongations of ACL (7 %)

5 ruptures during sport activity2 with poor femoral tunnel positionning

DuringDuring the the samesame time :time :8 ruptures occured at the opposite ACL (4 years after surgery to the other knee)

Literature with long follow-up

• Johnson & Eriksson (1984) 8 years• Aglietti (1992)• Demsey & Tregonning (1993) 9 years• Dejour & Ait si selmi (1995)

(comparisons are not easy : criteria #, follow-up #)

There are few well documented series after 10 years

Role of the extra-articular reconstruction

Not easy to analyse independently of the ACL

• Nothing to be gained from the adding of lateral plasty– Roth (1987)– Strum (1989)– O Brien (1991)

• Reduction of the pivot shift– Jensen Slocum Larson (1983)– Noyes Barber-Westin (1991)– Lerat (1997)

« Influence of a lateral extra-articular plasty on the results of ACL reconstruction with the patellar tendon. Follow-up 4 years »

JL. Lerat, A. Mandrino, JL. Besse, B. Moyen, E. Brunet-Guedj.Revue de Chirurgie Orthopédique, 1997, 83, 591-601

ConclusionsConclusionsConclusions

• Good results if we compare to the literature

• Confirmation of the good quality of patellar tendon as an ACL substitute.

ConclusionsConclusionsConclusions

Quadruple interest of this prospective study :

• Original reconstruction of ACL + Lateral extra-articularreconstruction with a single transplant using the quadriceps tendon and thus preserving the ilio-tibial band and the control of varus stability

• Confirmation of the efficiency of a lateral reconstruction inchronic cases

• Interest of Radiological measurement of the drawer (1979)

• Interest of a early agressive rehabilitation program (1979)

ThankThank youyou

prepre--opop laxitylaxity

Pre-opLAXITY

varusextension

varusflexion

valgusextension

valgusflexion

none 129 116 121 95slight 6 16 14 28++ 2 2 2 11

severe 0 1 0 1